Patient (Pt) is coming in for colonoscopy and hemorrhoidectomy under general anesthesia. After lying down and going to sleep, the patient is rolled onto his stomach. The bed contorts with the whirring of engines to drop his legs down and lift his ass proudly to the Heavens. We pull his legs apart and place them into the anal stirrups. Two physicians (HPS and Brian) are sitting on stools between Pt’s legs for the show. Tape is applied to each ass cheek and then pulled around the bed for even “better” exposure.

The hemorrhoids are enormous and angry looking. They are each cut from the anus and the incisions sewed together. Brian, under the supervision of HPS, grabs the colonoscope. The c’scope is then fed into his rectum and maneuvered past the sigmoid colon, snaked around the splenic flexure, pushed along the transverse colon, and then descends down the ascending colon for a a good look at the cecum. No polyps or other masses. Everyone is happy. Brian pulls the colonoscope out of the colon, HPS leaves the room to dictate the operative note, and I begin taking down the drapes. Brian takes off his sterile gloves, gown, and plastic face shield. I lean over the patients back to release a clip holding the drapes in place and my weight compresses the patient.

PHBLLEEBBTHURUUUURP!

During a colonoscopy, air is pushed into the colon to inflate it for “exposure”. As the colonoscopy is finished, this air is typically sucked out so as to leave the Pt as comfortable as possible when they leave. Brian forgot to do this.

The shit sprays everywhere. On his cheeks, his eyelids, his forehead, arms, and neck. It turns his blue scrubs brown. The anesthesiologist screams. Brian is on the other end of the room, having kicked himself reflexively from the patient on his sliding stool. In fact, he’s still coasting towards the far wall as we watch him panic, trying to find a poopless place on his body to wipe away the poop on his body. He can’t find anything. The panic sinks in its teeth.

“Somebody HELP ME!” But we’re the ones that need help. We’re twisted in knots, fighting for gulps of air as we struggle against the laughter. We’re not even human right now: the laughter owns us. The patient begins to wake up. Hearing the commotion, HPS reenters the room.

“Oh GOD!” And HPS leaves the room to dry heave in the hall. It’s been 40 seconds since my last breath and my chest is starting to spasm. I can’t tell if we’re even making noises anymore or if we’re all quietly dying of laughter.

The scrub nurse walks over to Brian and, afraid of the hand-off, throws a towel at him. He begins to wipe himself clean. The patient is awake now with the embarrassment that only a person with his asshole winking at a room full of laughter can ever truly know. Brian has wiped his face and is now storming to the wash room to clean himself. He walks by the head of the bed and the patient pieces it together.

“Oh, I’m so sorry if I pooped on you.”
Brian manages an “It’s okay” before walking out.

*I wrote the following for friends and family a long time ago. Thought I’d share*

My third year is fractured by discipline and geography. Watch me as I hurdle across the great states of Pennsylvania and New Jersey through Surgery, OBGYN, Psychiatry, Pediatrics, Family Practice and Internal Medicine. I plan on writing once/twice per rotation.

For now, I’m beginning my third month of Surgery in Pittsburgh.

Who knows for certain, but odds are that I’m going to cut people for a living. Others want to be physicians in order to help people and that’s great. I’m just looking for stabbings minus the jail sentence.

We begin with Trauma, a painfully slow field punctuated by bursts of exhausting speed like the sprintings of the obese. From 6am to 6pm, we waddle the four corners of the Trauma ICU tending to the most serious cases from the last week. It takes 12 hours to see 15 patients for several reasons, though I am unaware of any good ones. Attending Spanish Physician has sleep apnea. This causes him to fall asleep standing up at times in the middle of rounds while someone works up the nerve to tactfully clap their hands. Attending Scottish Physician never uses two words when ten would do. He has held court on the following:

George Washington’s teeth

The French and Indian War

Mussolini’s v. Hitler’s fascism

Why flying airplanes is so difficult

Things back in his day

Imagine it: twelve hours every day spent on two hours of real work. You can’t escape. Attendance is mandatory. “If you ask him a question, I sear to God, I will kill you.” So I don’t ask questions. I just stand there, eyes glazed over, praying for a midday TRAUMA ALERT: 30M 20FT FALL FROM TREE +LOC HEAD LAC ETOH 5MIN ETA VIA GRND.

Drunks in trees. All the time.

I like responding to traumas because I am an important member of the Trauma Team. I am make-sure-they’re-naked guy. I stand poised, trauma scissors in the air with blades just slightly opened, waiting to cut away your dignity. You’re a trauma, you’re getting naked. No negotiation.

“Are you cutting my dress?”
“Yes, ma’am. We have to check you for injuries.”
“But I just fainted!”
“Yes, ma’am. But you fainted in a car. That makes you a ‘trauma’. Please stop moving your head; you may have a broken neck.”

Because it is hard to schedule traumas, there was little time in the operating room and the majority of this service felt like ER with knives. Fun, but glad when it ended. After three weeks, I moved on to the Colorectal surgery service.

You would never guess it, but poop surgery is great. The incisions are huge and the anatomy is straightforward, so it’s easy to play along. You take people that are absolutely miserable with constant nausea, vomiting, diarrhea, fevers, etc who can’t remember what it feels like to enjoy a meal. You cut out their colon: cured. Thanks to preoperative bowel preparation, there is actually very little stool (or succus) during surgery, which is fortunate when you’re a 250lb ex-football player turned Head Poop Surgeon (HPS) that vomits at the sight of it. During an operation where the small bowel was being cut in two, some green stool began to leak from the lumen.

“Oh my God, I’m gonna throw up. IMGONNATHROWUP! Brian, get it away! GETITAWAY!” HPS stutters back from the table, dry-heaving.
Brian wipes away the small amount of stool with a lap pad as those not twisted in hysterics stare on in horror at HPS’s reaction.
“I hate that. Oh, I hate that. Okay, let’s finish.”

Poop surgeons don’t like to be called “poop surgeons,” by the way. It’s no use explaining to them how funny it is. They just don’t get it.

Much has been made of “pimping”, the art of harassing medical students with questions in order to expose their ignorance. This is often described as being malignant. This has not been my experience. If anything, I have wished aloud to be asked more questions in order to better learn what is and is not important and to have a chance to show that I am studying in my spare time. Barely touched on Trauma, Colorectal gave it a good try. With mixed results. Here is a smattering:

“Christian, what is the social muscle? ”
“The tongue, sir?”
“No. It’s the anal sphincter. If it doesn’t work, you have no social life and no home. Watch a bunch of monkeys. They hang out together, all poop, and then they have to move. That’s why monkeys don’t have houses.”

“Christian, what are the indications for surgery?”
“Hemodynamic instability.”
“That’s a trauma answer. This man is having his colon removed, so that’s a pretty stupid answer for this man, isn’t it.”
“Sorry, sir. Any condition that has been refractory to medical management for which a surgical solution exists that is not otherwise contraindicated.” To myself: booyah.
(Pause). “Wrong. Um, what’s the most important thing to remember when irrigating the abdomen?”
“To suck the fluid back out, sir?”
“Um. Wrong. It’s to not use too much. Okay smart guy, what’s that?”
“The uterus, sir.”
“Good.”

Playing the role of the good surgical student slowly earns you privileges in the OR. I have the privilege of cutting sutures with the scissors. I have the privilege of holding and pulling things. At the end of the case, I have the privilege of using staples to close the skin or use sutures to close a small hole. Execute each of these without error, and you are praised. As much as I gripe about being compared favorably to a seven-year-old with appropriate motor skills, the simple “nice job” can make your day. I was graduated to eight-year-old after being offered the scalpel to make the first incision for a case. This was no nick, but instead went from his sternum to his pubis. When HPS made it clear that I was going to make the cut and the he was not joking, the surgical masks in the room nearly popped off from the slacked jaws.

Like analogies, tides come in waves. I’ve been writing a lot of them lately and trying them in conversations. If there’s no one around, I try them in made-up conversations. This is the charitable way to say that I’ve been talking to myself more and more.

This is an outlet problem. I’m nervous for something. It’s either too big, too important, or too scary to handle myself. But coming anyway. It was college, when I wrote a journal every day for two years without fail. Then I stopped. It was medical school, when I started RWT. I stopped two years ago. Now, it’s the next biggest thing that happens in your life. Before the next thing.

And I’m talking to myself.

I went to tell you, someone, anyone about it. In a few days, I will be engaged.

But right now, I’m wearing an ugly sweater. She wore it a few nights ago. Tonight, I want to write two of the most outrageous stories form my trip through Asia. I want to write about my time in South Africa and the month I spent in Ecuador. But what I’m really thinking about is these backward buttons.

I hope every guy learns it eventually*, but the buttons on female clothing are opposite to ours. In the past, men were dressed by maids. Male clothing has buttons were women are used to them – on the left. Thinking back on times where I’ve needed her to fix a cuff for me, I think about how this intimate and nice thing is because of her practiced fingers.

She’s left for the coast two days ahead and we’ll see each other tomorrow. It’s hard to focus. It’s hard to think that the holiday cookies I’m eating or the champagne I’m drinking is anything but a way to blunt something else. Looking for a way to focus on what I have to write tonight, it’s becoming easier to understand that this too-tight and oh-so-perfectly ugly christmas sweater is more than a writing tool. It is what I need to understand about myself at this moment.

Erik Erikson is about the only thing I liked about Pediatrics. He had this theory about the stages of development through which everyone must pass. If I’m figuring out something tonight, I hope it’s everything. I’ve been looking for the first two teeth to click correctly, finally, so that this whole thing zips together and closed. I’m looking back at my life and seeing how it falls into what he described.

Looking back at the stages, I remember them. I wrote through them. And it’s finally making sense to me why my writing has come and gone so many times even when I wished it stayed. It makes sense to me why I thought I was going to be a psychiatrist. It makes sense to me why I’m writing now.

I need to work through this. When I came to the Caribbean I had my last and perfect opportunity to define myself. And now that I have, I’m ready for the next thing. But I have to work through it still.

Thank you for being patient, for thinking I’d write again, for caring that I disappeared, and for reading at all.

Cheers, topher.

*I first discovered this at a Goodwill. I was looking for cheap pants for the new school year. I found this pair of beige corduroy pants that fit perfectly. I didn’t recognize the manufacturer nor did I know what “size 8″ meant, but I wore the hell out of them just the same.

“It is human to have a long childhood; it is civilized to have an even longer childhood. Long childhood makes a technical and mental virtuoso out of man, but it also leaves a life-long residue of emotional immaturity in him.”

Grenada is in my thoughts again. Since leaving it as a transfer to Drexel, I have had an amazing time as a 3rd and 4th year student, dabbled in the world of pick-up artists, applied for and failed to match into a Plastic Surgery residency, traveled to Ecuador for a month to learn Spanish, traveled to South Africa for shits and giggles, filed a patent on a medical device to help hospital workers wash their hands more often, worked on a few more books and projects with the folks over at First Aid, become a research physician at a prestigious institution, met my future wife, and I have manage to put a ring on her finger.

In April, I’m headed back to Grenada as a Visiting Professor of Anatomy and I am excited to see what they’ve done with the place.

In my absence, transferring and quitting have been the most popular topics on this blog. I am really happy that people have found a place to discuss both. I am disappointed in myself for not finishing the “transferring” section of this blog and giving it the attention that it deserves. At one time, I thought I might finally write a book about it. But for now, I am building a new site for that topic which will do the issue justice.

I don’t have a handle on what’s happened here, though it’s completely under my control. The Rumors Were True began as a manifestation of envy. I’ve told this story before, but I used to write just to make my friends and family laugh. With some practice, I got to the point where I had a reputation for pulling it off. And as it has happened so many times when I find myself becoming successful with something originally challenging, I bore of it and stop. So it was with writing for a laugh.

I needed a new challenge.

Two years ago, I found PURRTY GUD and I was blown away by his writing. I thought, “here’s a guy that is just better than me. Usually with some work, I can match people at things like this but not him and not now. He’s just better.” I knew I was forever less, so it was a perfect place to begin. And fueled by my feeling that I would never measure up and my jealousy for this talent, I began RWT.

In the beginning, it was very stupid. It was very distant. I’m not sure that someone who started reading at that point would have ever gotten a picture of who I was, other than somewhat snarky and in love with my own diction (you can laugh at that). But slowly I started to write things that were a little more naked and personal, and it was from these things that I received the strongest responses. Soon, the goal of every week was to write something good enough to be included in Grand Rounds and I chased that for months.

At this point, I wanted to be famous. I fell into the trap of obsessing over my statistics. How many people read my last story? Where were they from? How long did they stay? Who thinks my story is good enough that they’re telling people to read it? And so on. Finally, I reached a point where 100 people were coming to read every day and I was very proud. I wrote to a friend of mine, “In one year, 1000 people will come to read me every day.” This is what passed for my goals.

Beginning in August of 2006, I was intoxicated with medical school and the Welcome to Grenada project. I was writing about my love of Anatomy, my research, my introduction to clinical medicine on the islands, and about the islands themselves. Writing the WTG guide began to take over the RWT, and I split it into its own blog with its own management, but already the character of my writing was changing again.

I began writing about what I was thinking. I began reacting to things instead of planning every word. I started writing about Flash Raves, MicroCredit, and I struck a chord with my reaction, “A Lazy Attack on Atheism.” What I wrote was becoming less and less about medicine and more and more about me. It was because I was becoming more comfortable with the thought that strangers could know my secrets and that would be “okay”. It was also because I was running out of ideas, grasping at straws. I thought often about ending RWT.

I tried to suck some water from the well by writing Pancakes Every Morning. I hosted Grand Rounds because I was hungry for some new kind of challenge. Immediately after, I gave everything I had left to The Old Man, which I consider to be the best thing that I have ever written and the only thing I ever did outside of my comfort zone. And after that, I felt done.

I twitted away the next month writing pieces I didn’t care about. I started researching the business and law behind the practice of medicine because it was interesting and I was ignorant. But I was empty. I had nothing left worth writing and I had stopped finding joy in it.

RWT should have died long ago save for the USMLE. I found in writing about that experience a steady supply of “new” and a comfort zone of writing guides for others. Telling someone what to do is an easier thing than writing to evoke a feeling. I was jumping over the lower bar.

And then I found a reason to write again.

I became so engulfed in the material while preparing that I began to see deeper into it than I had before, and I was able to spot conflicts and connections as easily as you would spot marinara on a pressed white shirt. It became clear to me. I discovered this while using the First Aid for the USMLE book, and when I went to find a website that listed its errors, I found not a single one.

And I complained about there not being a source. I have written before about my own guiding principle: The Categorical Imperative. In this case (as in all cases), complaining required action: since I wished someone had already made a list of errors, I could not complain about it unless I was willing to make the thing that I felt was missing. This became my reason for writing: to compile a perfect and complete list of errors. To scour the book as few others had ever done and, in doing so, to know more about everything.

Before I knew it, RWT was no longer a place for my writing: it was a one-stop-shop for USMLE adivce, textbook corrections, and so on. This was more interesting to more people than my stories ever were and I quickly reached an average of 1000 visitors a day. The success was discouraging, and insomuch as my statistics were a progress report, I felt that connection had been completely lost.

And as it has happened so many times when I find myself becoming successful with something originally challenging, I bore of it and stop. So it was with writing about medicine.

Perhaps I set the bar too low or that I chose the wrong metric for success. Whatever the case, it couldn’t have happened at a worse time as I left for Asia and from writing for the next six weeks. Long distance for any weak relationship delivers the final blow. I felt done with writing. In the weeks after returning, my only reason for coming back here was to update and maintain the USMLE portion of this site. Whatever drove me before was gone.

And now as I begin the second half of my medical school career, I find I need something from this space, from whomever has stuck around this long to see if I have anything left to say, that I cannot get. RWT feels ruined by its success. From the First Aid Errors project, I earned the attention and interest of the First Aid Team. Shortly, I will begin working for them. This is fantastic news that I have not been able to share with you until now.

At the same time, I am applying for transfer to US medical schools, and the successes of the Welcome to Grenada Guide and the FA Errors have become selling points on my application. This has made RWT public (as it always was) and has stripped me of any illusions of anonymity. I have never been as diligent about keeping myself anonymous as I could or should have been, but its loss has never been so obvious to me as it is now. At a time where I need this space to be a place for me to be my most honest, where I need the catharisis of venting and a chance to share my frustrations with feeling uncertain about my future and my fears that medicine has facets of it that I feel strongly against, RWT has begun to feel as much a liability as an asset.

I feel watched. I feel known in an uncomfortable way. I feel twisted into self-censure.

I cannot write the way that I need to on RWT anymore. It no longer feels like my journal and a safe for my memories. Now, it feels like a bulletin board of updates and other stale things. I could continue to write here about happy things, about funny things, about critiquing things but I cannot write about sad things, frustrating things, about hating things. I am not Ying or Yang, but the pair, and I worry that this simple thing that is true about all of us could hurt me to show it. I worry about a dishonest portrayal of what life is like.

And now I think it is time for RWT to end. Not deleted (because people still find use in it), or forgotten (it remains the safe for everything that happened to me early on in this new life) or regretted (I learned so much about myself while writing it).

It will end because I was sloppy and couldn’t keep it from mixing with the reasons not to write.

***

Why do you write?

I write to think.
I write to remember.
I write to help others.
I write to stretch and twist and understand new ways of seeing the world.
I write to help people understand me, if for no other reason than to feel understood. To connect.
I write to make you a part of my life so that mine feels larger.
I write for vanity.
I write for the freedom of anonymity.
I write because I need to feel whole and this gets me there.

***

I look back to PURRTY GUD now and I better understand him. He was anonymous to the world as he wrote but his family and friends were all reading. He wrote about it ruining things, about feeling like it was bringing more harm to him than good. When he graduated, he decided to end the blog and start a new one for his residency. It was then that he revealed his name. It wasn’t a few weeks before it completely disappeared. He gave out his email address for those that wanted to know if he was ever writing again and if they could follow him to this new anonymous place.

I am still writing. I have a bank of stories that I’m going to release after the Match about everything that has happened over the last two years. With all my free time since ignoring the internets, I’ve been able to do other fun things. This is one of them. Also, this is my face and my voice.

As far as the cube goes, I bought one in November of 2007 and went to Lars Petraus’ website.

It took my about two days to figure out my first solve (basically following the website move for move). It was another week before I could solve it without looking at my cheat sheet of written algorithms. Another week before I was sub-5 minutes. A week later it was 3 minutes. I spent about a month hovering around 90 seconds and have been stuck at 45-60 seconds for the past three months without any real improvement.

I have no plans to solve it blindfolded, but appreciate all the people that tell me they won’t be impressed until that happens. You people suck.

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About

My name is “topher”. I used to be a MidWesterner and am now a Caribbean medical student at St. George’s University. Before leaving the states, I wondered at all the rumors I heard coming from the Caribbean. Do they study on the beach? Do their professors sip cocktails with little umbrellas in them during the exams? Are they really learning medicine in a Third World Country?